HomeMy WebLinkAboutMiscellaneous - 1 High Street Bldg 21Z
Location )/69 S
No. Date
TOWN OF NORTH ANDOVER
Other Permit Fee
TOTAL
Check # � /tn -A :� -R
A
15113
RAZi $ ,Sr,) .
$ /so—!
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Building Inspector
Certificate of Occupancy $
CHU
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # � /tn -A :� -R
A
15113
RAZi $ ,Sr,) .
$ /so—!
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Building Inspector
TOWN OF NORTH -ANDOVER BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
Section for Official Use Onl
BUILDING PERMIT NUMBER: DATE ISSUED:
�.
SIGNATURE:
Commissionerfl or f Buildings Date
01Building
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
c y
CJCN OL
Map Number Parcel Number
i
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proliosed Use
Lot Area Frontage ft
1.6 WELDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
Required
Provided.
1.7 Water Supply M.G.L.C.Q. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public 0(Private ❑ Zone Outside Flood Zone ❑
Municipal On Site Disposal System ❑
2.1 Owner of Record
y�}�E ProptI?-14es i)sh , AM ST .UJ Ai4%`4
Name (Print) Address for Service:
S;e-6 7Fj - YS3-
Signature Telephone
2.2 Authorized Agent
lZpPuU1C_
Name Print Address for Service:
7,5"a - 0cq e� 9
Si a Telephone }
3.1 Licensed Construction Supervisor Not Applicable ❑
Address License Number
LA-) d 1
Licensed Constructio pervisor_
��Eviration-Date
C•v
gn re Telephone
egistered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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90
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Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the
issuance of the building permit.
Signed affidavit Attached Yea .......❑ No ....... ❑
5.1 Registered Architect:
Name:
Address
Signature
Telephone
Company Name:
Responsible in Charge of
Not Applicable ❑
Area of Responsibility
Registration Number
Expiration Date
Name:
Address:
Signature Total
Not applicable ❑
Registration Number
Expiration Date
Name:
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
Company Name:
Responsible in Charge of
Not Applicable ❑
New Construction ❑ Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑ Demolitions
Other ❑ Specify
Brief Description of Proposed Work:
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑
A4 ❑ A-5 ❑
1A
IB
❑
❑
B Business ❑
2A
2B
2C
Hereby authorize 1L &u' 'S L t (_
My behalf, in all matters relative two work authorized by this
,�,Ef
Signature of Owner
IU/G� to act on
permit application
/0-18 -o
Date
USE GROUP Check as applicable)
CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑
A4 ❑ A-5 ❑
1A
IB
❑
❑
B Business ❑
2A
2B
2C
❑
❑
❑
C Educational ❑
F Factory ❑ F-1 ❑ F-2 ❑
H High Hazard ❑
3A
3B
❑
❑
IInstitutional ❑ I-1 ❑ I-2 ❑ I-3 ❑
M Mercantile ❑
4
❑
R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑
5A
5B
❑
❑
S Storage ❑ S-1 ❑ S-2 ❑
U Utility ❑
M Mixed Use ❑
S Special Use ❑
Specify:
Specify:
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Use Group:
Proposed Hazard Index 780 CMR 34:
BUILDING AREA EXISTING if applicable)
PROPOSED
Number of Floors or Stories Include
Basement levels
Floor Area per Floor s
Total Area s
Total Height ft
Independent Structural Engineering Structural Peer Review Requir I W Yes ❑ No
❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, VOL as Owner of the subject property
Hereby authorize 1L &u' 'S L t (_
My behalf, in all matters relative two work authorized by this
,�,Ef
Signature of Owner
IU/G� to act on
permit application
/0-18 -o
Date
�t'3s / NIJUIC /Qtr7
I- LanArw4$ as Owner/Authorized
Agent
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury
Print Name
Signa of Owner/Agent Date
Item
Estimated Cost (Dollars) to be�5"
Completed by sz4k x } iN
% `���, '.,A.
permit applicant � � ` ,� , x` ''� �.., Y �'- � �.
1. Building
(a) Building Permit Fee
co
Multi Tier
2 Electrical
(b) Estimated Total Cost of
Construction from (6)
3 Plumbing
`.J�-0
Building Permit fee (i) X (b) /3
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
OD o O O
Check Number 0!?3'
Al r i S r...� t�� x -, � �`�(�, .��" 4ri;�,i �iV •:i�1 /�.+(7i'$ L. 'F3� %..'�.,,� ?s ,.i.,.f R? Y k % �y iy�:��YiE "A YC T Yv�'i h � y�3.5� t i ..-�F•.+R �;�C S{"`4 �Lx '�,.
(l-1 %i�fi ��-. 7� Lh i:.,t f `f5`}•. t 'Sr+i�H(I �Mt, �1 Z � i S3,C� ) �iZ ����� lY�I� J� �� y ,�6 c'tYF._ ? .+%v{_�:� �3Hf CFy { fii (. ? fi L .'.Y � ori /:5� � 47t. .t{.
( '. 4F j 4 ✓f {t5}k.t : i i t
:.
.. .:i. rJ l N H 'tt`':.F L ''3 `i
�?.5"4�
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR THVIBERS 1 sr 2ND 3RD
SPAN
DEMENSIONS OF SILLS
DEMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
ti
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� I am a homeowner perf'otating all work myself.
n I am a sole proprietor and have no ant working in any capacnY
I
am an etnP lover providing workaW comPa�bon for my employees working on
listed
V Inlet nronrietor. central contractor, or homeowner (circle one) and have hired the conttadors
who have
on's cars' imprisonment as well as o.N P.—....� ._ -- ----
csyr of this statement say be fornardcd. to the Offict or Investigations of tkx DIA for coverage Verification
-
7
ry the pains cs ofoedu that the iefoasadon provided above is lure and eorrrd
I ail hereby Cert iy
Pate
sig
_--?hoot#
P" name
tfuial use only do not write is this arcs to he completed by city or fawn official
permit/ticeax f—Building DePartsent
city or town Otkcuti'= Boars
Oseloctmen's office
(3 check if immediate response is required Olkaktr Department
piwne 11; under
pntact person:
1evisd 3/" FJA)
1-n oroiatidn aod-%sfi=ucfiohs
Marachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
em;06yees. As quoted fivth t -he "law", an employee is defined as revery person in the service of another under any
cover act of hire, express or implied, oral or written.
An extployer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the fioregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the.
owwr.of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwel.iing house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or oo the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGI, chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits may be submitted to the Department of
Indtorial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
affidavit should be returned to the city or town that the application for the permit or license is being requested,
not The Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required
to ollain a workers' compensation policy, please call the Department at the number listed below.
Cit-3or Towns
Plea le be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the $idavit for you to fill out in the event the.Office of Investigations has to contact you regarding the applicant Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
Thc�:Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
pie, -5e do not hesitate to give us a call.
ThADepartment's address, telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
600 Washington Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 7274900 eat. 406, 409 or 375
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BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
6
Number: -CS 045457
Birthdate:' 03/08/1964
Expires: 03/08/2003
Restricted: Oil
JAMES H BURNS
22 PARISH LN
BOXFORD, MA 01921
Tr. no: 1090 i
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CZ,.,.4
Administrator
- - t j
J
OCT -18-2001 THU 04:42 PM YALE AT CROSS POINT FAX NO. 978 454 6394 P. 02
a
YAL- E
October 18, 2001
Mr. Michael McGuire
Building Inspector
Town of North Andover
27 Charles Street
North Andover, MA 01845
Re: Shed Demolition (Building 21)
North Andover Mills, One High Street, North Andover, Massachusetts 01845
Dear Mr. McGuire:
Yale Properties USA has authorized Republic Building Contractors, Inc. to obtain the
necessary permits to remove the existing structure referenced above.
Thank you for your assistance in this matter. if you should have any questions, please
4 contact me at (978) 453-6666.
Sincerely,
YALE PROPERTIES USA
--/k IJ4&5�ek--e� ---
Lauren M. Wallace
Assistant Property Manager
cc: Jim Ward, Republic Building Contractors
il
Cross point, 900 Chelmsford Street, Lowell, Massachusetts 01851 Tel.: (978) 453-6666 Fax: (978) 454-6394
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
toN Mrt 1-000'`1Y6
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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